In Part 1 of this series, I described the impending “Great Consolidation” in the Digital Health and Employer Health space using the past history of the platform wars that we saw with the desktop computer, mobile phones, and electronic health records to demonstrate that an ecosystem of 1,000’s of solutions is simply not sustainable. The Great Consolidation will cause chaos and carnage, similar to that seen in these other markets, but will also bring equal promise and prosperity for the Full Stack solutions that can continue to deliver the most value to employers and members while aggregating the biggest network effects.
But let’s step back and talk through what a “Full Stack” solution should actually be. Most of the time, there is a strong over-indexing on technology and we have certainly seen this in healthcare. How many times have you heard, “I’m a technologist, I am new to healthcare, but I am here to fix it” (think Google Health, Microsoft Healthvault, and most recently IBM Watson)? Almost always, and well beyond healthcare, too much credence is given to the technological ingenuity of a digital product or set of products, which is erroneously considered to be a marker of success. And no matter how many times a new technology has over-promised, we still are sucked into the belief that the technological underpinnings will be the key differentiator. Hal Varian, the Chief Economist at Google, once remarked that “In Silicon Valley, they always say you overestimate what can be done in a year, but you underestimate what can be done in ten years.” This is not simply a way of expressing Gartner’s Hype Cycle, it’s recognition that the drivers of true adoption and change are more centered on human and social factors than technological capabilities. As Andrew Scott, an economist at the London Business School has noted, “social ingenuity lags and does not always follow technological ingenuity.”
Don’t get me wrong. We will absolutely need technical ingenuity to be one of the main catalysts driving new possibilities—we should expect logarithmic growth of new products, exponential new tools to analyze and predict health factors, and capabilities to leverage an ever-growing set of data libraries. But technology is the enabler—NOT the driver—of the change that is required to achieve the richly imagined future of truly responsive and cost-effective care.
I actually think it is more useful to think in terms of new capabilities that will need to be brought to bear as opposed to new technical features. Instead of focusing on features, I think it is much better to describe the functional principles and pillars upon which the Full Stack vision will be based. And, as you can see, I believe that these will be based on broader economic, social, and ultimately human characteristics.
“Real” Full Stack Primary Health will have the following inter-related capabilities:
- Engagement Capabilities: Engaging the populations you serve is the critical first step in being able to help members, not just by responding to current needs, but also by helping them embrace a lifestyle approach that reduces the need for “sick care” in the first place. Without specific strategies and capabilities that engage people in their health, at the time and using the media they want, your solution will be unable to have real or sustainable impact. “If a digital health tool fell in the forest, would it make a sound?”
- Care Capabilities: This is a critical, and surprisingly overlooked component of achieving Full Stack care. The actual care model—how you actually treat members, your biopsychosocial approach, how care teams are organized, the tools used to power team-based care, and of course, the accountability of teams to achieve individual and collective health outcomes—is incredibly important (and very difficult to achieve at scale successfully). Tuning a care model to address the full continuum of care is no joke. And, as we often say, there ISN’T an app for that hand-to-hand combat required to deliver advanced Primary Health.
- Payment Capabilities: Our current system perpetuates payment models that reward activity over achievement, that pay for volume rather than value, and more often than not trade objective clinical outcomes for obligatory ceremonial oblations at the altar of fee for service. Aligning benefit design with the payment model as part of a truly Full Stack care delivery approach is the Commercial Advantage “catalyst” the Employer Health market has been waiting for. Without payment reform, technology just enables bad practice in higher fidelity.
- Outcomes Capabilities: The final pillar must be that the Quadruple Aim is actually achieved. None of the chutes and ladders of the traditional system, the bells and whistles of digital health, nor the gimmickry of cost-shifting stand up in the sunlight of the repeatable, scalable, and irrefutable evidence of lower cost as delivered by foundational Primary Health. We need bigger, better, and badder (as in “good”) evidence that Primary Health delivers real results. If this is done right, we no longer have to be great sales people, our clients should be able to just do the simple math!
When you look at these pillars, it’s clear that none would be achievable without being appropriately “powered by” technology. Even the term Full Stack is borrowed from the representative analog found in integrated front and back end software development and products. But the Full Stack won’t be about “tech” per se because in healthcare—given both larger vertical and broader horizontal demands—there must be a human component as well. Turns out that perhaps uniquely in the healthcare industry, the familiar refrain gets flipped to “powered by humans.” Currently, this may be considered a contrarian view…but you can already feel it becoming a consensus perspective.
There’s an old adage: “When all you have is a hammer, every problem looks like a nail.” So often the technical orientation of many Full Stack aspirants is misapplied when the right answer actually relies on human-powered capabilities. The Great Consolidation will continue to winnow out the technically narrow point solutions to more fully embrace the clinically abundant integrated care delivery. This is why companies like Crossover, who leverage technology to do the hard work of “touching” members directly, will continue to flourish while those that are digitally uni-dimensional will continue to be deflowered.
Bringing Engagement, Care, Payment, and Outcomes together in a single care delivery model isn’t just a cool innovation—it is the logical extension and natural conclusion of the Great Consolidation. And in this Full Stack vision, I believe we can take great consolation.
In Part 3, I’ll look at how I think this Full Stack ecosystem will coalesce around three organizing options, and how the “Currency of Trust” will prove to be the best identifier of value creation, as well as the key differentiator for anyone seeking to be THE platform of choice for employers, members, and the industry.
Scott Shreeve, MD 